Muscle velocity recovery cycles in myopathy

OBJECTIVE

To understand the pathophysiology of myopathies by using muscle velocity recovery cycles (MVRC) and frequency ramp (RAMP) methodologies.

METHODS

42 patients with quantitative electromyography (qEMG) and biopsy or genetic verified myopathy and 42 healthy controls were examined with qEMG, MVRC and RAMP, all recorded from the anterior tibial muscle.

RESULTS

There were significant differences in the motor unit potential (MUP) duration, the early and late supernormalities of the MVRC and the RAMP latencies in myopathy patients compared to controls (p < 0.05 apart from muscle relatively refractory period (MRRP)). When dividing into subgroups, the above-mentioned changes in MVRC and RAMP parameters were increased for the patients with non-inflammatory myopathy, while there were no significant changes in the group of patients with inflammatory myopathy.

CONCLUSIONS

The MVRC and RAMP parameters can discriminate between healthy controls and myopathy patients, more significantly for non-inflammatory myopathy. MVRC differences with normal MRRP in myopathy differs from other conditions with membrane depolarisation.

SIGNIFICANCE

MVCR and RAMP may have a potential in understanding disease pathophysiology in myopathies. The pathogenesis in non-inflammatory myopathy does not seem to be caused by a depolarisation of the resting membrane potential but rather by the change in sodium channels of the muscle membrane.

Cardiac Abnormalities in Adult Patients With Polymyositis or Dermatomyositis as Assessed by Noninvasive Modalities

OBJECTIVE

Cardiac events are a major cause of death in patients with idiopathic inflammatory myopathies. The study objective was in a controlled setting to describe cardiac abnormalities by noninvasive methods in a cohort of patients with polymyositis (PM) or dermatomyositis (DM) and to identify predictors for cardiac dysfunction.

METHODS

In a cross-sectional study, 76 patients with PM/DM and 48 matched healthy controls (HCs) were assessed by serum levels of cardiac troponin I, electrocardiography, Holter monitoring, echocardiography with tissue Doppler imaging, and quantitative cardiac (99m) Tc-pyrophosphate ((99m) Tc-PYP) scintigraphy.

RESULTS

Compared to HCs, patients with PM/DM more frequently had left ventricular diastolic dysfunction (LVDD) (12% versus 0%; P = 0.02) and longer QRS and QT intervals (P = 0.007 and P < 0.0001, respectively). In multivariate analysis, factors associated with LVDD were age (P = 0.001), disease duration (P = 0.004), presence of myositis-specific or -associated autoantibodies (P = 0.05), and high cardiac (99m) Tc-PYP uptake (P = 0.006). In multivariate analysis of the pooled data for patients and HCs, a diagnosis of PM/DM (P < 0.0001) was associated with LVDD.

CONCLUSION

Patients with PM or DM had an increased prevalence of cardiac abnormalities compared to HCs. LVDD was a common occurrence in PM/DM patients and correlated to disease duration. In addition, the association of LVDD with myositis-specific or -associated autoantibodies and high cardiac (99m) Tc-PYP uptake supports the notion of underlying autoimmunity and myocardial inflammation in patients with PM/DM.

Learning effect of isokinetic measurements in healthy subjects, and reliability and comparability of Biodex and Lido dynamometers

The aim of this study was to examine the learning effect during a set of isokinetic measurements, to evaluate the reliability of the Biodex System 3 PRO dynamometer, and to compare the Biodex System 3 PRO and the Lido Active dynamometers on both extension and flexion over the elbow and the knee at 60 degrees s(-1). Thirteen (nine women, four men) healthy participants were measured five times using the Biodex and once using the Lido dynamometer. The intervals between the first four tests were 20 min, and 1 week between tests 4 and 5. Between Biodex and Lido measurements there was a 20 min time interval. When comparing the first five measurements (Biodex), no systematic effect over time and an excellent reliability were found with respect to elbow and knee flexion and extension. No difference in muscle strength (Nm) between the Biodex and Lido was observed for knee flexion (P = 0.59), knee extension (P = 0.18) and elbow extension (P = 0.63). However, elbow flexion showed a 14.8% (95% CI: 11.2-18.4%; P = 0.0001) higher peak torque on Biodex. In conclusion, no learning effect was observed and the Biodex proved to be a highly reliable isokinetic dynamometer. A difference was observed when comparing Biodex and Lido on elbow flexion, but the difference did not outrange the expected variation found with a typical isokinetic measurement, which is why both sets of equipment seem applicable in clinical practice.

Synthesis of 5-azacastanospermine, a conformationally restricted azafagomine analogue

The 5-aza-6-deoxy analogue of castanospermine (+/-)-5a and its 1-epimer (+/-)-5b was synthesized. The synthesis started from the known compound 5-benzyloxy-7-hydroxyhepta-1,3-diene, which was protected and subjected to Diels-Alder reaction with 4-phenyl-1,2,4-triazoline-3,5-dione to give two epimeric adducts. One of these was transformed through epoxidation, acetolysis, a series of side-chain transformations that converted it into a terminally protected aldehyde, deprotection, and hydrogenolysis/reductive amination into 5a. By a similar set of reactions the other adduct epimer was converted into 5b. The castanospermine analogue 5a was a weaker inhibitor of almond beta-glucosidase and rice alpha-glucosidase than castanospermine (2) or 1-azafagomine (4), but was considerably more potent than its epimer 5b. This suggests that these enzymes have a strong preference for binding substrates or azasugars with the 6-OH in an axial conformation.

Soluble intercellular adhesion molecule-1 (sICAM-1) and soluble interleukin-2 receptors (sIL-2R) in scleroderma skin

In order to investigate whether soluble intercellular adhesion molecule-1 (sICAM-1) and soluble interleukin-2 receptors (sIL-2R) were present in scleroderma skin, and to compare their levels to concentrations measured in plasma and clinical parameters, we examined suction blister fluid and plasma from 13 patients with systemic sclerosis and 11 healthy volunteers. Suction blisters and biopsies were from the transition zone between normal skin and scleroderma, and uninvolved abdominal skin. The levels of sICAM-1 and sIL-2R were significantly increased in both plasma and suction blister fluid from systemic sclerosis patients compared with healthy volunteers. ICAM-1 was localized to vessels and perivascular mononuclear infiltrates by immunohistochemical methods. IL-2R was expressed by CD3-positive cells. The elevated levels of sICAM-1 and sIL-2R in suction blister fluid point towards activation of endothelial cells and T cells in both the transition zone and uninvolved skin of systemic sclerosis patients.

The steroid-sparing effect of long-term plasmapheresis in pemphigus: an update

Glucocorticoids and immunosuppressive agents can induce remission in most pemphigus patients, but mortality remains at 5 to 15% as a result of side effects. We reviewed the adjunctive effect of long-term plasmapheresis in 8 pemphigus patients. Four cases had been resistant to conventional therapy. One or 2 large-volume plasmapheresis treatments were given monthly over 5 to 141 months. All patients, were in clinical remission within 2 months. Relapses seldom occurred: the patients stayed in remission 90% (40-94) (median, ranges) of the period. In all cases the daily dose of glucocorticoid was reduced. The prednisone level could be decreased from 38 (15-80) mg/day to 7.5 (2.5-35) mg/day (p = 0.002). The overall level of other immunosuppressive agents remained unchanged, except in 1 patient for whom cyclosporine was introduced. This indicates that long-term plasmapheresis could have a steroid-sparing effect and clinical efficacy in pemphigus.

Increased levels of type I and III collagen and hyaluronan in scleroderma skin

The aminoterminal propeptide of type III procollagen (PIIINP) and the carboxyterminal propeptide of type I procollagen (PICP) and hyaluronan (HA) were measured in plasma and suction blister fluid from 13 systemic sclerosis patients and 11 healthy volunteers. Suction blisters and skin biopsies were from the transition zone between normal skin and scleroderma, and uninvolved abdominal skin of patients. The median value of suction blister PIIINP from the transition zone was 38% higher than suction blister PIIINP from uninvolved skin. PIIINP was localized to the dermis by immunohistochemical techniques. PICP and HA levels in blisters from the transition zone were 87% and 53%, respectively, above the levels measured in uninvolved skin. Furthermore, PICP and HA blister levels from the transition zone were 67% and 63%, respectively, higher than the levels measured in healthy volunteers. In plasma from scleroderma patients levels of PIIINP and HA were 38% and 127% higher, respectively, than in plasma of healthy volunteers. The plasma PICP level was not significantly higher in scleroderma patients. Finally, PICP, PIIINP and HA levels were several times higher in suction blister fluid than in plasma. The data indicate that a fibrogenetic process takes place in the transition zone of scleroderma. The method may be used to monitor the progression of scleroderma skin lesions in vivo.

The use of serologic markers for collagen synthesis and degradation in systemic sclerosis

BACKGROUND

Systemic sclerosis is characterized by excessive accumulation of collagen in all involved organs. Serum markers of collagen synthesis and degradation, the aminoterminal propeptide of type III procollagen (PIIINP), the carboxyterminal propeptide of type I procollagen (PICP), and the crosslinked telopeptide of type I collagen (ICTP), can be measured.

OBJECTIVE

Our purpose was to investigate these markers in different subgroups of untreated patients with systemic sclerosis and in patients before and after various types of therapy. PIIINP and PICP were also investigated in blister fluid from involved and uninvolved skin.

METHODS

Sera from 97 patients and suction blister fluid from 13 patients were radioimmunoassayed.

RESULTS

The highest levels of PIIINP and PICP were found in blister fluid from involved skin. Patients with systemic sclerosis had higher serum levels of PIIINP than control subjects. The highest levels were found in patients with diffuse cutaneous systemic (type III) sclerosis; increased serum PIIINP was also characteristic of type II limited cutaneous systemic sclerosis. Most patients with limited cutaneous type I systemic sclerosis had normal levels. Serum PICP was within normal limits in all three types of systemic sclerosis. Variations in ICTP type I collagen degradation in general followed PICP. Immunosuppressive drugs significantly reduced PIIINP, whereas no significant decrease was found after photopheresis. PICP and ICTP also diminished after treatment with D-penicillamine and cyclophosphamide given together with prednisone.

CONCLUSION

PIIINP can be recommended for monitoring collagen synthesis in systemic sclerosis. Our data support the use of immunosuppressive therapy for this disease.

The steroid-sparing effect of long-term plasmapheresis in pemphigus

Glucocorticoids and immunosuppressive agents can induce remission in most patients with pemphigus, but mortality remains at 5 to 15% due to complications from these drugs. We reviewed the adjunctive effect of long-term plasmapheresis in 8 patients with pemphigus. Four cases had been resistant to conventional therapy. One or two large-volume plasmapheresis treatments were given monthly for 5 to 73 months. All patients were in clinical remission within 2 months after the addition of plasmapheresis. Relapses of pemphigus seldom occurred, and the patients stayed in remission 90% (40-100%) (median and ranges) of the plasmapheresis period. In all cases the daily dose of glucocorticoid was reduced. The prednisone level could be decreased significantly from 38 (15-80) mg/day to 10 (5-35) mg/day (p = 0.008). The overall level of other immunosuppressive agents remained unchanged, except in one patient where cyclosporine was introduced. This first report of long-term plasmapheresis demonstrates clinical efficacy in pemphigus and a considerable steroid-sparing effect.

The high-affinity folate receptor of normal and malignant human colonic mucosa

The hypothesis that folate depletion is a risk factor for development of colonic neoplasia prompted us to study the presence of a putative folate receptor in human colon mucosa. Binding of 3H-folate to normal and malignant mucosa studied by equilibrium dialysis was of high-affinity type (K = 10(10) L/mol) and displayed apparent positive cooperativity. Radioligand dissociation was slow at pH 7.4, but rapid at pH 3.5. As compared to methotrexate, 5-formyltetrahydrofolate was a potent inhibitor of binding. Gel filtration revealed a 25 kDa and a 100 kDa peak of folate-binding activity. Immunoreactivity studies were performed with rabbit antibodies against human 25 kDa milk folate-binding protein. Immunoblotting showed a single band at 65 kDa, and tissue sections exhibited immunostaining of mucosal areas. The present folate receptor with characteristics similar to those of other high-affinity folate-binding proteins may serve as a regulator of intracellular folate concentration in colon mucosa.

Skin scoring in systemic sclerosis: a modification--relations to subtypes and the aminoterminal propeptide of type III procollagen (PIIINP)

Forty-one patients with systemic sclerosis were investigated with a new and simple skin score method measuring the degree of thickening and pliability in seven regions together with area involvement in each region. The highest values were, as expected, found in diffuse cutaneous systemic sclerosis (type III SS) and the lowest in limited cutaneous systemic sclerosis (type I SS) with no lesions extending above wrists and ancles. A positive correlation was found to the aminoterminal propeptide of type III procollagen, a serological marker for synthesis of type III collagen. The skin score is considered simpler than previous methods and is recommended for more general use.

Plasma endothelin and the aminoterminal propeptide of type III procollagen (PIIINP) in systemic sclerosis

Forty-four patients with systemic sclerosis and 3 patients with localized scleroderma were investigated for plasma endothelin and aminoterminal propeptide of type III procollagen (PIIINP). Although there was an overlap between plasma levels of endothelin in patients with systemic sclerosis and healthy controls, the mean value of the patients was significantly higher than in controls. Plasma endothelin was normal in all 3 patients with localized scleroderma. The highest levels of plasma endothelin were found in patients with type II and III systemic sclerosis with the largest cutaneous involvement, and in patients with the scleroderma-specific antibodies Scl-70 and anticentromere antibodies. Extremely high values were found in a patient who experienced a renal crisis and in a patient who had her lower leg amputated due to severe vasculitis. A positive correlation was found between plasma endothelin and serum PIIINP. This, together with the fact that in systemic sclerosis the vascular lesions are the earliest, would seem to support the theory that endothelial cell damage could lead to increased secretion of endothelin and subsequent fibrosis in this disease.

Folate receptor of human mammary adenocarcinoma

Binding of 3H-folate to human mammary tumor homogenate was of a high-affinity type (K = 10(10) M-1) and displayed apparent positive cooperativity. Radioligand dissociation was slow at pH 7.4, but rapid at pH 3.5. As compared to methotrexate, 5-formyltetrahydrofolate acted as a strong inhibitor of radioligand binding. Gel chromatography of radioligand-labeled homogenate of tumor tissue revealed three peaks: a small > or = 110 kDa peak and two major peaks of folate-binding activity (M(r) approximately 25 kDa and M(r) approximately 100 kDa). Mammary tumor tissue showed immunostaining with rabbit antibodies against human milk folate binder. A parallel elevation in the concentrations of folate-binding protein and triglyceride in tumor tissue as compared to normal tissue adjacent to the tumor was compatible with the localization of folate-binding protein in the triglyceride-rich fraction of mammary gland homogenate.

Dysplastic naevus: histological criteria and their inter-observer reproducibility

Forty melanocytic lesions were examined in a pilot study, which was followed by a final series of 100 consecutive melanocytic lesions, in order to evaluate the inter-observer reproducibility of the histological criteria proposed for the dysplastic naevus. The specimens were examined in a blind fashion by four observers. Analysis by kappa statistics showed poor reproducibility of nuclear features, while reproducibility of architectural features was acceptable, improving in the final series. Consequently, we cannot apply the combined criteria of cytological and architectural features with any confidence in the diagnosis of dysplastic naevus, and, until further studies have documented that architectural criteria alone will suffice in the diagnosis of dysplastic naevus, we, as pathologists, shall avoid this term.

[Significant prognostic factors for recurrence-free survival after surgical treatment of head-neck melanoma]

The clinico-pathological and therapeutic data of 512 patients with clinical stage I invasive head and neck melanoma of the skin were re-evaluated. There were 287 females and 225 males. The median age at primary surgery was 65 years, range 18 to 96 years. The median observation period was 5 years, range 1 month to 25 years. Sex, age, ulcerated tumor and tumor thickness were found by Cox multivariate regression analysis to act as independent prognostic factors for recurrence-free survival. In addition, size of the excision margin was found of no significance for survival without relapse when adjusting for the independent risk factors.

The elderly at folk high schools. An educational experience

The following article tells about a special feature of Danish society, namely the Danish Folk High School. The traditional folk high school has existed since the era of Grundtvig, but after 1970, efforts were made both by means of hard work and by legislation so that today we are able to offer courses for our senior citizens at four different high schools. Rapid technical development threatens to bring our society into imbalance. One can fear that the spiritual world, overrun by technocrats, is close to break down. However, the Danish folk high school affords an enormous chance to fight back by helping people to reestablish their self-reliance, appreciating human values like solidarity and the exchange of thoughts and dreams. The Danish folk high school is one possible antidote for a world of too much body and too little spirit.

Calcium metabolism in postmenopausal osteoporotic women is determined by dietary calcium and coffee intake

Eighty-five patients, age 48 to 77 y with postmenopausal crush fracture osteoporosis, were investigated using a 7-d combined calcium balance and 47Ca tracer-kinetic turnover method taking the dermal calcium loss into account. Individual dietary records were obtained based on a 4-d registration at home before hospital admission and on questioning by a dietitian. The following dietary constituents were estimated: energy content, protein, methionine, cysteine, calcium, phosphate, magnesium, coffee, fiber and vitamin C. All patients were served individual diets based on the dietary records during study. Dietary calcium was measured in duplicates of all the meals served. All urine and feces were collected and analyzed for calcium content. The 47Ca kinetic data were analyzed according to a modification of the expanding calcium pool model. The overall calcium balance correlated significantly to energy content (r = 0.31, P less than 0.005), protein (r = 0.22, P less than 0.05), calcium (r = 0.28, P less than 0.01), phosphate (r = 0.27, P less than 0.02) and coffee (r = -0.21, P less than 0.05). However, a multiple backward linear regression analysis disclosed that only calcium (rp = 0.38, P less than 0.0005) and coffee intake (rp = -0.25, P less than 0.05) significantly influenced calcium balance. The equation was: calcium balance (mmol/d) = 0.14 x (dietary calcium, mmol/d) - 0.0016 x (coffee intake, mL/d) - 3.62. A coffee intake in excess of 1000 mL could induce an extra calcium loss of 1.6 mmol calcium/d, whereas intakes of 1-2 cups of coffee per day would have little impact on calcium balance.

[Over-the-counter weight-reducing preparations]

This report deals with over-the-counter products sold currently in Denmark for weight reduction. Only oral products (alternative medications and food supplements) are included. The report includes 35 such products. The aims of the report are to provide a common, factual basis for the debate about weight-reduction products and to present proposals for regulations that improve the conditions for patients and health professionals to make their choice of the optimal products. Current laws and administrative regulations are found to be complicated, obscure and inadequate. For most products, documentation for efficacy and safety is inadequate and health hazards are probable using several of the products. It is recommended 1) that obesity should be considered as a disease also in a legal/administrative context, 2) that an effective and objective registration of side-effects to alternative medication and food supplements is established, 3) that these products are tested for efficacy and safety before being marketed, 4) that the entire product information is made easily accessible, 5) that products without any documented effect are clearly labelled with this information and 6) that weight loss products involving health hazards are excluded from the market.

[Dietary treatment of diabetes mellitus. Background and rationale for recommendations in the 1990's]

Individual dietary regulation is still an important part of all forms of treatment of diabetes. In insulin dependent diabetes (IDDM) it is rational to advise the patient 1) to arrange his diet so that this results in a low glycaemic response, which implies a relatively high intake of dietary fibre and polysaccharides, 2) to distribute the food into 5-6 daily meals and 3) to consume a low-fat diet. This prevents too pronounced postprandial hyperglycaemia and hypoglycaemia between meals. Simultaneously, insulin sensitivity is increased and not only the insulin requirement but also peripheral hyperinsulinism tend to be reduced. Dietary regulation in IDDM is thus a compensation for the defective synchronization of variations in the plasma levels of glucose and insulin in the present day forms of insulin therapy. Nine out of ten diabetic patients are non-insulin dependent (NIDDM). The great majority are obese, 50% have essential hypertension and just as many have dyslipidaemia (raised serum triglyceride and reduced serum high density lipoprotein (HDL)-cholesterol). The condition is characterized pathophysiologically by insulin resistance in muscle, fat and liver tissue and delayed and frequently reduced glucose-stimulated secretion of insulin. The most important element in dietary regulation in NIDDM is, therefore, reduction of the energy content of the food with the object of achieving and maintaining reduction in weight. Even moderate reduction, in the majority of NIDDM patients, will have the effect that metabolism of carbohydrates and lipids becomes approximately normal on account of considerable increase in insulin sensitivity and to a lesser degree increased secretion of insulin.(ABSTRACT TRUNCATED AT 250 WORDS)

Improved early alimentation after radical hysterectomies without the traditional use of stomach tube

Energy and protein intake was studied for 12 days after radical hysterectomy in 16 patients, half of whom followed a traditional postoperative regimen (i) including a stomach tube until air-passage had taken place after which liquid food, protective food and full diet was gradually introduced. In the new regimen (ii) the stomach tube was not used, liquid alimentation was given from the first postoperative day and full diet as soon as the patient desired it. This early start of oral alimentation was well tolerated, without side effects. Compared with the conventional regimen, it resulted both in a higher average protein intake (i: 31 g protein/day, ii: 46 g protein/day, p less than 0.02) and in a higher energy intake (i: 3624 kJ/day, ii: 4956 kJ/day, p less than 0.01).

Biological behaviour of cutaneous malignant melanomas

The classification proposed by Clark et al. of cutaneous malignant melanoma into 3 groups: lentigo maligna melanoma (LMM), superficial spreading melanoma (SSM) and nodular melanoma (NM) was based on a correlation between histology and biological behaviour. Many studies have shown different growth rates, prognosis and incidence of antecedent benign nevi for each of these groups, confirming that each is a separate entity with its own biological behaviour. The recent proposal that acral lentiginous melanoma (ALM) is a distinct clinico-histological entity, however, is more difficult to accept. Many melanomas on acral locations are histologically intermediate between SSM and ALM and the epidemiological value of classifying ALM as an entity separate from SSM is doubtful.

Depth of invasion and tumor thickness in primary cutaneous malignant melanoma. A study of 2012 cases

In 2012 patients with primary malignant melanoma of the skin the primary lesion was reviewed microscopically and the depth of invasion was staged and the tumor thickness was measured. It was possible to improve the prognostic value of Clark's method by dividing Clark's level IV (reticular dermis) into 2 subgroups, level IV A and level IV B, corresponding to the upper half and the lower half of the reticular dermis, respectively. Level IV A lesions were correlated with a significantly better prognosis than level IV B lesions (p less than 0.0025). By combining depth of invasion and tumors thickness it was found that for each level of invasion (except for level II) the prognosis deteriorated significantly with increasing tumor thickness. Level II indicated an excellent prognosis regardless of tumor thickness. Conversely, it was found that for each subgroup of thickness (except for 0.76 - 1.50 mm) the prognosis was not influenced by level of invasion. In melanomas measuring 0.76 - 1.50 mm in thickness the survival rate was significantly deteriorated, the deeper the invasion (p = 0.0003). The prognostic value of measuring tumor thickness was superior to that of staging depth of invasion. In melanomas 0.76 - 1.50 mm thick, however, additional classification of depth of invasion improved the prognostic value significantly.

Partial regression in thin primary cutaneous malignant melanomas clinical stage I. A study of 486 cases

486 patients with primary cutaneous malignant melanoma clinical stage I were examined in order to evaluate the prognostic importance of partial regression in thin lesions. All the melanomas measured 1 mm or less in maximal thickness. The study showed that past regression with fibrotic scar tissue adversely affected survival in patients with thin melanomas. The 10 year survival was 95% for patients without regression in contrast to 79% for patients with past regression. It was, furthermore, demonstrated that active regression without fibrotic scar tissue did not influence survival significantly. The wider and the thicker the fibrotic area, the poorer the survival. Although the prognostic importance of this finding was not statistically significant, we suggest that the horizontal width of the fibrotic area in particular may be a valuable prognostic guide in thin melanomas with past regression.

Therapeutic and clinico-pathological factors in the survival of 1,469 patients with primary cutaneous malignant melanoma in clinical stage I. A multivariate regression analysis

Therapeutic and clinico-pathological data of 1,469 patients with clinical stage I malignant melanoma of the skin without histological evidence of fibrotic areas of regression were examined by multivariate regression analysis. In accordance with a previous analysis anatomical site of tumour, tumour thickness, level of invasion, mitotic rate, ulceration, lymphocytic reaction, dominant type of invasive tumour cell, and sex were found to act as independent risk factors. The present analysis, furthermore, showed that size of resection margin, diagnostic biopsy, removal of the deep fascia, age at surgery, as well as presence and depth of nevus cells did not influence prognosis when adjusting for the independent risk factors.

Survival with primary cutaneous malignant melanoma, evaluated from 2012 cases. A multivariate regression analysis

Cox's multivariate regression model for survival data was applied to 2,012 patients with primary cutaneous melanoma in order to evaluate the relative prognostic value of numerous clinical and histological variables and to establish their prognostically most efficient combination. The material was divided into 4 groups according to the size of resection margin of the primary lesion (less than 2.0 cm, 2.0 cm, 2.1-4.9 cm, and greater than or equal to 5.0 cm). Data were analysed separately in these 4 groups and equivalent results were obtained. The risk factors were clinical stage, site of tumour, tumour thickness, level of invasion, mitotic activity, ulceration, lymphocytic reaction, predominant type of invasive tumour cell and partial regression. When accounting for these factors, histological type, nuclear pleomorphism, nucleolar size, vascular invasion, pigmentation, verrucous growth pattern, and dermal elastosis were without prognostic influence. The effect of sex and age of patient was uncertain and both variables, therefore, were retained in the model. By using Cox's method it is possible to make a qualified estimate of the survival for the individual patient.

DNA ploidy-characteristics of human malignant melanoma analysed by flow cytometry and compared with histology and clinical course

Flow cytometric analysis of nuclear DNA content is valuable for indicating ploidy- and proliferation abnormalities in surgically removed human malignant melanomas. In 35 primary cutaneous melanomas, 20 metastases of melanoma in skin and lymph nodes, and 16 nevi the DNA distribution was analyzed by flow cytometry and compared with a variety of histological parameters and the subsequent clinical course. Heteroploid DNA distributions with increased polyploid or aneuploid fractions were found in 26 primary melanomas (74%), 14 metastases (70%), and 4 nevi (25%) indicating tumor clones with an abnormal nuclear DNA content. Three or more cell clones in a single biopsy was found in 10 primary melanomas, 2 metastases, and 1 nevus. The frequency of heteroploidy was significantly higher in primary and secondary melanomas than in nevi (p less than 0.001) and was correlated significantly with a high mitotic activity (p less than 0.002), marked nuclear pleomorphism (p less than 0.01), large nucleoli (p less than 0.01) and a thickness of the primary melanoma of more than 2.25 mm (p less than 0.02). Such histologic findings in malignant melanomas have been shown previously to be correlated with a bad prognosis. No significant correlation was found between heteroploidy and the histologic type of melanoma or the level of invasion. A 2-year clinical follow-up showed that more patients died from melanoma if the DNA distribution in the primary or secondary melanoma was heteroploid (6/26; 23% and 8/13; 62% respectively) than if it was diploid (0/9; 0% and 2/5; 40% respectively). However, the differences were not statistically significant. It is concluded that heteroploidy 1) is not an absolute criterion of malignancy, 2) is significantly correlated with histologic features indicating marked cellular anaplasia, and 3) is apparently correlated with a bad prognosis.

Histological type and biological behavior of primary cutaneous malignant melanoma. 1. An analysis of 1916 cases

In 1916 patients with primary malignant melanoma of the skin (excluding palms, soles, and nailbeds) the primary lesions were reviewed microscopically and classified according to Clark's system into lentigo maligna melanoma (85), superficial spreading melanoma (1234), and nodular melanoma (513). Differentiation between the types was not possible in 84 melanomas (4%). By correlating type of melanoma with various clinical and histological features, it was found that the 3 types differed significantly from one another with regard to growth rate of tumor, antecedent nevus, dominant type of invasive tumor cell, and prognosis. The study thus supported the basic principle of the classification employed, that the 3 histological types represent distinct entities of cutaneous melanoma with different clinical, cellular, and behavioral characteristics. As originally described by Clark, the growth rate was greatest for nodular melanoma, followed by superficial spreading melanoma, and least for lentigo maligna melanoma. It is recommended that this classification be employed in the histological typing of cutaneous melanoma as 1) it is readily applied to the vast majority of melanomas, and 2) it seems to delineate separate clinico-pathologic entities of cutaneous melanoma, which might be correlated with aetiological differences.

Histological type and biological behavior of primary cutaneous malignant melanoma. 2. An analysis of 86 cases located on so-called acral regions as plantar, palmar, and sub-/parungual areas

Primary cutaneous malignant melanomas are generally divided into 3 separate clinico-pathological variants, lentigo maligna melanoma (LMM), superficial spreading melanoma (SSM), and nodular melanoma (NM). Recently an additional variant, acral lentiginous melanoma (ALM), has been defined, occurring on acral regions, defined as plantar, palmar, and sub-/parungual areas. Histological examination of 86 primary melanomas on acral regions revealed 24 (28%) acral lentiginous melanomas (ALM), 23 (27%) superficial spreading melanomas (SSM), 18 (21%) nodular melanomas (NM), and 21 (24%) unclassifiable melanomas. No LMM was seen. The prognosis was found to be the same in patients with SSM and ALM. However, by correlating histological type with frequency of antecedent nevus, duration of melanoma and dominant invasive tumor cell, it was demonstrated that histologically typical ALM differed from histologically typical SSM by their infrequent origin from antecedent nevi, their lower local growth rate, and their more frequent content of spindle cells. These findings support ALM as a valid melanoma subtype only when clearly defined histologically.

The intra-lesional variation of type, level of invasion, and tumour thickness of primary cutaneous malignant melanoma

In order to evaluate the prognostic importance of type of melanoma, level of invasion and tumour thickness in a retrospective study of cutaneous melanomas, it is prerequisite that the available histological material be representative. To investigate this condition 55 primary cutaneous melanomas were studied randomly by serial block technique. The histological classification of each tissue block as to 1) type of melanoma, 2) level of invasion, and 3) tumour thickness was correlated with the overall classification of the corresponding whole tumour. The typing included 6 groups: Superficial spreading melanoma, lentigo maligna melanoma, nodular melanoma, acral lentiginous melanoma, melanoma of unclassifiable type, and nevoid lesion. The depth of tumour invasion was graded by 5 levels according to Clark et al. The tumour thickness was measured in mm as described by Breslow, and arranged in 6 groups (0--0.75 mm, 0.76--1.50 mm, 1.51-2.25 mm, 2.26--3.00 mm. 3.01--6.00 mm, and more than 6.00 mm). The study revealed a consistently of 95% (52/55) between the type of the central cross section and the type of the whole tumour. In 96% (53/55) of the central cross sections the level of invasion was equal to that of the whole tumour. In 95% (52/55) of the central cross sections the tumour thickness was situated in the same group as that of the whole tumour. It is concluded that type, level and thickness of malignant melanomas can be evaluated in retrospective studies if central cross sections of the melanomas are available for histological examination.

Malignant melanoma of the foot. A clinicopathological study of 125 primary cutaneous malignant melanomas

In a retrospective study of 125 primary cutaneous malignant melanomas of the foot treated from 1949 to 1977 the prognostic importance of various histological and clinical factors was observed. Clinical stage, location of tumour on the foot, level of invasion, tumour thickness, mitotic rate, and presence of ulceration correlated well with survival, while sex and histological type did not. A histological transition was found between the superifical spreading type and the acral lentiginous type, indicating a close biological relationship between the two types of melanoma.

Metastatic melanoma with balloon cell changes: an electron microscopic study

A case of metastatic balloon cell melanoma is presented. The balloon cells are ultrastructurally characterized by the presence of numerous cytoplasmic vacuoles and abnormal melanosomes, which confirm their melanocytic origin. The study supports the concept that the cytoplasmic vacuoles represent grossly dilated melanosomes. The value of electron microscopic examination is emphasized in order to distinguish these lesions from other malignant clear cell tumors.